Clostridium tetani : Diagnosis, treatment and Prevention

Clostridium tetani : Diagnosis, treatment and Prevention


Diagnosis of tetanus

Based entirely on clinical findings: 

  • History of an injury
  • Particularly one in which either soil or fecal material has been introduced
  • 6-12 days before the onset of typical clinical findings.
  • Wound should be cultured in suspected cases.

Other laboratory findings may be –

  1. Leukocytosis
  2. Muscle enzyme levels may be raised
  3.  Electromyogram 
  • Show continuous discharge of motor units a
  • Shortening or absence of the silent interval.

Treatment of tetanus

  • Treatment of tetanus includes :

1. Antimicrobial therapy :- 

  • Eradicate vegetative cells
  • Penicillin and metronidazole are first line drugs. 
  • Clindamycin and erythromycin are alternatives for penicillin – allergic patients.
  • Tetracycline is not used.

2. Antitoxin :-

  • Neutralize circulating toxin. 
  • All wounds must be thoroughly cleaned soon after injury
  • Human tetanus immune globuline (TIG) is the preparation of choice.
  • Administered within time it neutralizes tetanus toxin and significantly lowers the mortality
  • Serious wound + uncertain about  immunization should receive both
  1. Tetanus toxoid (active immunity)
  2. Tetanus immune globulin (Passive immunity)

Control of muscle spasms :-

  • Muscle spasms cause laryngospasm or sustained contraction of ventilatory muscles. 
  • Therefore painful and life threatening.
  • Benzodiazepines (Diazepam, lorazepam, midazolam) are used most commonly.
  •  Alternatives are Barbiturates and chlorpromazine. 
  • Mechanical ventilation used for spasms unresponsive to medications. 
  • Other agents include propofol, dantrolene, intrathecal baclofen, succinylcholine and magnesium sulfate.

Respiratory care :-

  •  Intubation or tracheostomy, with or without mechanical ventilation may be required.

Autonomic dysfunction :- 

  • For sympathetic overactivity labetalol, esmolol or clonidine may be used.

Vaccine :- 

  • Patient recovering from tetanus should be actively immunized.

Prevention

Active immunization

  • Protective level of antitoxin > 0.01 IU/ml serum
  • Active immunity offered by tetanus toxoid is effective in 100% of the patients 
  • Adsorbed toxoid are more beneficial
  • Should never freeze

Monovalent Vaccine:

  • 2 dose of purified tetanus toxoid (IT) should be given at interval of 1-2 month
  • Ist booster after 1 year of 2nd dose.
  • 2nd booster after 5 years of 3rd dose.

Combined Vaccine :

  • DPT .

Passive immunization :

  • Human tetanus hyper immunoglobulin (TIG) is best prophylactic to use.
  • Toxin already bound to neural tissue is not affected.

Combined active and passive immunization:

  • Patient is given TIG in one arm
  • TT in other arm
  • Followed by another dose of TT 6 weeks later and third dose 1 year later.
  • TIG contraindicated during pregnancy.
  • The purpose of antitoxin is for immediate temporary protection
  • The purpose of tetanus toxoid is for long lasting protection
  • TT is useful even after 12 hours have elapsed following injury.

Pregnancy

Primigravida

  • Tetanus toxoids appear safe during pregnancy
  • Administered intramuscularly.
  • 0.5 ml tetanus toxoid is given at 6 weeks interval for 2 times
  • The first one to be given between 16-24 weeks.

Multigravida (completely immunized in last 5 years): 

  • 1 booster dose is sufficient

Multigravida (partially immunized in previous pregnancy in last 5 years):

  •  2 doses, 1 month apart, after I trimester.

Multigravida (unimmunized in previous pregnancy in last 5 years):

  •  2 doses, I month apart, after I trimester

 Multigravida (completely immunized in previous pregnancy earlier than 5 years): 

  • 2 doses, I month apart, after I trimester.

Exam Important

Diagnosis of tetanus

  • Muscle enzyme levels may be raised

Treatment of tetanus

  1. Antimicrobial therapy 
  2. Antitoxin :-
  • Human tetanus immune globuline (TIG) is the preparation of choice.
  • Administered within time it neutralizes tetanus toxin and significantly lowers the mortality
  • Serious wound + uncertain about  immunization should receive both
  1. Tetanus toxoid (active immunity)
  2. Tetanus immune globulin (Passive immunity)

Prevention
Active immunization

  • Protective level of antitoxin > 0.01 IU/ml serum
  • Active immunity offered by tetanus toxoid is effective in 100% of the patients 
  • Adsorbed toxoid are more beneficial
  • Should never freeze

Monovalent Vaccine:

  • 2 dose of purified tetanus toxoid (IT) should be given at interval of 1-2 month
  • Ist booster after 1 year of 2nd dose.
  • 2nd booster after 5 years of 3rd dose.

Combined Vaccine :

  • DPT .

Passive immunization :

  • Human tetanus hyperimmunoglobulin (TIG) is best prophylactic to use.
  • Toxin already bound to neural tissue is not affected.

Combined active and passive immunization:

  • Patient is given TIG in one arm
  • TT in other arm
  • Followed by another dose of TT 6 weeks later and third dose 1 year later.
  • TIG contraindicated during pregnancy.
  • The purpose of antitoxin is for immediate temporary protection
  • The purpose of tetanus toxoid is for long lasting protection
  • TT is useful even after 12 hours have elapsed following injury.

Pregnancy

Primigravida

  • Tetanus toxoids appear safe during pregnancy
  • 0.5 ml tetanus toxoid is given at 6 weeks interval for 2 times
  • The first one to be given between 16-24 weeks.

Multigravida (completely immunized in last 5 years): 

  • 1 booster dose is sufficient

Multigravida (partially immunized in previous pregnancy in last 5 years):

  •  2 doses, 1 month apart, after I trimester.

Multigravida (unimmunized in previous pregnancy in last 5 years):

  •  2 doses, I month apart, after I trimester

 Multigravida (completely immunized in previous pregnancy earlier than 5 years): 

  • 2 doses, I month apart, after I trimester.

 

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